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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0406 <br /> (Ed.8-84) <br /> PREMIUM DISCOUNT ENDORSEMENT <br /> The premium for this policy and the policies,if any,listed in Item 3 of the Schedule may be eligible for a <br /> discount.This endorsement shows your estimated discount in Items 1 or 2 of the Schedule.The final calculation <br /> of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium <br /> subject to retrospective rating is not subject to premium discount. <br /> Schedule <br /> 1. State Estimated Eligible Premium <br /> First$5,000 Next$95,000 Next$400,000 Balance <br /> NC 10.9 12.6 14.4 <br /> 2. Average percentage discount: % <br /> 3, Other policies: <br /> 4. If there are no entries in items 1,2 and 3 of the Schedule,see the Premium Discount Endorsement attached to your policy number: <br /> This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise stated. <br /> (The information below Is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. <br /> Insured: Senior Care of Orange County inc Premium(See Attached) <br /> Insurance Company: Markel Insurance Company Countersigned by <br /> WC000406 <br /> (Ed.8-84) <br /> e 1983 National Council on Compensation Insurance. <br /> 13 of 24 <br />